weu1e) labour Department: Labour REPUBLIC OF SOUTH AFRICA EMPLOYER'S REPORT OF AN OCCUPATIONAL DISEASE. Ferotice ws ony ‘COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 (ACT No, 130 OF 1993) Clin No, [Section 682) - Commissioner’ ls, forme ad patil ~ Annexure 12] ‘This report must be completed in respect of an alleged occupational disease which an employee when he reports alleges thatthe disease arisen out of and inthe course of his employment irrespective of the fact that he may have contracted the disease in the employment of a previous employer. NB: tis common knowledge that he symptoms of some diseases only appears years later after an employee might have left the employer's service where he was exposed. Itis therefore important to note that where a disease has been contracted in the employ of a previous employer, the cost ofthe claim, ift is accepted, shall not be set off against the employer in who's employ the disease was diagnosed, ‘This report must be forwarded tothe: Compensation Commissioner P.O. Box 955 Pretoria 001 [A separate form must be completed for each employee. 2. This report should not be held back until the medical reports have been obtained. 3, An employer who fails to report an occupational disease on this form within 14 days to the Compensation Commissioner is in terms of this Act guily af an offence and may be held lable for the full east af the claim 4, Please use the W.CL.2(E) form for the reporting of an accident. 5, Please keep record of an employee's address ithe has contracted an occupational disease and leaves your ‘employment in order that compensation if any may be awarded to him. FOR OFFICE USE ACCEPTANCE STAMP CONTROL, REPUDIATE EMPLOYER'S INDEX NAME DATEDECLARATION BY EMPLOYER OR AUTHORISED PERSON "nor declare that the partulars, shown in ems 1 to 40 ofthis report, fan abeged cccupatorll sease contacted by the ‘employes, ae fo thebestof my knowodge an boi! re and accurate ‘Sioned on tis day of 20. Signature EMPLOYER 41. Registered name with he Compensation Commissioner Registered number ofthis business with the Compensation Commissioner 2 3. Contact person Steet adress 5. Postal code 8. Postal adress 7. Postal code BTW Gon) 84 FaKro. (00) 9.2 Email address 10 E-maladdreseSituation of businessiarm 11, Nature of business, rade or industry eMPLoveey 12, Sumame 12, Frat names. 14. one. 1s, ooh M6. Sex [Male [Fema] 17. Martal state [Maried [Single] 18. Ctizen of 49. Perconl no 20. Oeaipaton 21, Steet adiess 22. Postal code 128. Period in your employ (yeeramonhs) 24. Is the inured employ working recor, waking member of @ CC, owner of oa partner in the business? ‘OCCUPATIONAL DISEASE 25, Nature ofasease 28. Date the dsease was aiagnosed 27 Allged cause of dsoase (Slat ie Sgont proce inthe work siace and with which he had ania that caused the dooase) 28. For how longa perod was he exposed 29, 0: snployes reported tre cisoase 30, Ploase mention t ename and adéross of the employer the employee didnot contact te disease in your employment 231. What type of work wats the employee performing with the other employer‘OTHER PARTICULARS OF EMPLOYEE 32, Eamings of emplayee tthe time of the clagnoss of he aisease Fuveek RiMonth ‘Gross cash esmings: {Incuting average payments for overtime andor commission ofa constant charac). [Alowanoes of a recurrent nate 8) Bonuses (le, 13th cheque) ) Otneralowances (spec nature). cash value of food ‘cash value of ree quar, 33, Wil the employee during temporary toll dsabiement continu to receive tom you Free Food? Free quarters? [YES 4, ve you prepared to make cash paymens during temporary dsabloment that lass longo than threo months? 38. you have alady pad cash tothe employee, sate the total amount R 38. Forwhat prod where such payments made? From t 4 » 4 4 37. Date on which the employee ceases work 38, Date on which the employee resumed work [employee has not yt resumed work, a Resurlion Raport (WGL 6} must be submit as san as he resumes dy FURTHER PARTICULARS 39. te employ respect ofan accident, give particulars ita your knowledge receive compansation previously forthe same disease or anihercisaateorin 40. Was the dice caused by the employeo's— {2} Deliberate non compliance of directions [YES | NO_] (@) Debate disregard ofthe terms of any law or statutory regulation designed to ensure the safety or heath of ‘employees or the prevention of diseases [YES | NO} (0. any replys i afrnative, the employee must ish an explanatory statement which must hen be atachod hereto together wth your comments hereon) [see REVERSE Si0E]Diseases Preumoconsisirosis ofthe pareneyma ofthe lung Ploural thickening causing significant impairment of function Broncnopulmonary disease Byssinosis ‘Occupational asthma Extrinsic alorgic alveot's [Any diaease or pathological manifestations Erosion ofthe tissues ofthe oral cavity or nasal cavity Dysbarism, including decompression sickness, barotrauma or osteonecrosis Any disease Allergic or iertant contact dermatitis Mesothelioma of the ploura or peritoneum or other ‘malignancy ofthe lang Malignancy of the lung, skin, larynx, mouth cavity oF bladder Mabgnancy of he lung, mucous membrane or the nose or assacated ar sinuses Mabgnancy ofthe lung Angiosarcoma of the liver Mabgnanecy of the bladder Leukaemia Tubereuiosis of the ung Brucolosis antorax ever Bovine tuberculosis Hearing impaiment Hand-arm vibration syndrome (Raynauel's phenomenon) Any oisease due to overstraning of muscular tendonous insertons Work (@) Any work inveiving the handling of or exposure to any of the following substances emanating from the workplace concerned: coxganic or inorganic frogenic dust asbestos or asbestos cus ‘metal carbides (hard metal) flax, cotton or sisal the senstsing agents (1) socyanates (2) platinium, nickel, cobalt, vanadium or chromium sats {3) hardening agents, including epoxy resins (@) acngie acs or derived acryatos {5) soldering or weding tunes (6) substances from animals or insects (7) fungi or spores {8) proteolytic enzymes (9) organi aust (10) vapours or fumes of formaldenyde, anhydrides, amines or diamines ‘mould, fungal spores or any ether allergen proteiaceious mater, 24 toluene -d-fsocyanates berylium, cadmium, phosphorus, chromium, manganese, arsenic, ‘mercury, ead, uorne, carbon sulde, cyanide, Rlogen derivates of Alpnate of aromatic hydrocarbons, benzene o fs homologues, nito- ycorine or other nvic acd esters, hydrocarbons, linlvlolu), alcoho's, ¥cals or ketones, acrylamide, or any compounds ofthe aforementioned Suostances irtants alkalis, acs or fumes thereof ‘abnormal atmospheric or water pressure lonising radlation from any source dust, liquids oF other extemal agents or factors asbestos o asbestos cust coalar pitch, asphalt or btumes or volatiles thereot rickel or ts compounds hxavalantchronium compounds, or bis chloromethy ether Vinyl chiride monomer ‘-amino-dpheny, benzidine, beta, naphty’amine,4-nitto-cpneny! benzene (1) ensaine silica (alpha quartz) (2) mycobacterium tuberculosis or MOTTS (mycobacterium other than tuberculosis transmitted to an employee during the performance of heath care work from a patient suflering rom active open tuberculosis bnicella abortus, suis oF melitensis transmitted twough contact with infected animals o* ther products bacilus antvacis iransmited through contact with infected animals or their products coxelia burnet emanating fom infected animals or their products mycobacterium ovis transmitted trough contac with infected animals or thoir products (@) Any work involving the handling of or exposure to any of the following: vibrating equipment repetitive movements Call Centre No.: 086 010 5350 - Fax No.: (012) 323-8627 or (012) 323-6986 E-m fo@labour.gov.za - Webs! : www.labour.gov.za